Failure to follow up a patient's symptoms delayed cancer diagnosis

What happened

Mrs G went to the hospital in summer 2011, complaining of chest pains and difficulty breathing. She had a chest X–ray and a scan to exclude the chance of a blood clot in her lungs. Staff diagnosed her with pleurisy and sent her home with antibiotics.

Over the next few weeks, Mrs G became progressively more unwell. She visited her GPs several times, but it was not until autumn that the GPs became concerned and arranged further tests. In winter 2011, Mrs G went into hospital as an emergency with severe pain and difficulty breathing. Following investigations, she was diagnosed with incurable lung cancer, and had palliative care.

In summer 2012 Mrs G became severely unwell again, but although she had an emergency appointment at the Trust, staff took no action until she was admitted a week later with pneumonia. Mrs G's condition initially seemed to improve with antibiotics, but she deteriorated and died several days later.

What we found

We partly upheld this case. The hospital should have made arrangements to follow up Mrs G's care in its chest clinic. Instead, the consultant wrote to Mrs G's GP, wrongly stating that her chest X–ray was clear and with no mention of any need for follow up. This led to a delay in Mrs G being diagnosed with lung cancer. If she had been followed up correctly, she would have been seen at the chest clinic in late summer 2011, and it was likely she would have been diagnosed with lung cancer then. While this would not have changed her prognosis or the course of the disease, Mrs G had to suffer for over two months longer before she received appropriate pain relief and palliative care.

There were no failings on the part of the GP Practice, because it received the wrong information when the Trust discharged Mrs G from hospital.

A delay in starting antibiotics in summer 2012 did not contribute to Mrs G's death.

Putting it right

The Trust apologised for the failings identified, and created an action plan to make sure that all patients who require follow up in future have this arranged for them.